STRESS ULCER PROPHYLAXIS SUMMARY

Size: px
Start display at page:

Download "STRESS ULCER PROPHYLAXIS SUMMARY"

Transcription

1 DISCLAIMER: These guidelines were prepared jointly by the Surgical Critical Care and Medical Critical Care Services at Orlando Regional Medical Center. They are intended to serve as a general statement regarding appropriate patient care practices based upon the available medical literature and clinical expertise at the time of development. They should not be considered to be accepted protocol or policy, nor are intended to replace clinical judgment or dictate care of individual patients. STRESS ULCER PROPHYLAXIS SUMMARY The incidence of clinically important gastrointestinal bleeding due to stress ulceration has declined with advances in the resuscitation and management of critically ill patients. Maintaining adequate systemic perfusion and initiating early enteral nutrition play a significant role in preventing stress ulceration. The efficacy of histamine-2 receptor antagonists (H2RAs), antacids, and proton-pump inhibitors (PPI) in preventing stress ulceration remains controversial. Prophylaxis using these medications is associated with potential adverse effects and drug interactions as well as additional cost. Given the controversial efficacy of these agents, their use should be limited to patients with acute risk factors. In addition, these guidelines are not intended for patients that have an indication for treatment with acid suppressive therapy, such as duodenal ulcer disease, gastroesophageal disease, etc. RECOMMENDATIONS Level 1 None Level 2 Chemoprophylaxis for stress ulcer prevention is indicated in patients with acute risk factors. Discontinue therapy when patients no longer have acute risk factors. Consider discontinuing therapy when a patient is tolerating full enteral feeding. Sucralfate is an acceptable alternative to a H 2 RA and may decrease the incidence and severity of ventilator associated pneumonia. A PPI is an alternative to a H 2 RA or Sucralfate in situations where these agents cannot be used. Level 3 A H 2 RA can be considered in patients that are NPO and have at least two potential risk factors for stress ulceration. Acute Risk Factors for Stress Ulceration Mechanical ventilation (>48 hours) without enteral nutrition Coagulopathy Hypoperfusion (shock, or organ dysfunction) High-dose corticosteroids (>250 mg/day hydrocortisone or equivalent) Significant burn injury (total body surface area 20%) Potential Risk Factors for Stress Ulceration Concomitant use of a non-steroidal anti-inflammatory drug (NSAID) Concomitant or recent corticosteroid use History of upper gastrointestinal (GI) hemorrhage, peptic ulcer disease, or gastritis EVIDENCE DEFINITIONS Class I: Prospective randomized controlled trial. Class II: Prospective clinical study or retrospective analysis of reliable data. Includes observational, cohort, prevalence, or case control studies. Class III: Retrospective study. Includes database or registry reviews, large series of case reports, expert opinion. Technology assessment: A technology study which does not lend itself to classification in the above-mentioned format. Devices are evaluated in terms of their accuracy, reliability, therapeutic potential, or cost effectiveness. LEVEL OF RECOMMENDATION DEFINITIONS Level 1: Convincingly justifiable based on available scientific information alone. Usually based on Class I data or strong Class II evidence if randomized testing is inappropriate. Conversely, low quality or contradictory Class I data may be insufficient to support a Level I recommendation. Level 2: Reasonably justifiable based on available scientific evidence and strongly supported by expert opinion. Usually supported by Class II data or a preponderance of Class III evidence. Level 3: Supported by available data, but scientific evidence is lacking. Generally supported by Class III data. Useful for educational purposes and in guiding future clinical research. 1

2 INTRODUCTION Stress ulceration is a form of hemorrhagic gastritis that may occur following trauma or critical illness (1). Although not completely understood, the pathophysiology is likely multifactorial. Inadequate systemic perfusion resulting in poor mucosal blood flow, and reperfusion injury play an important role in the development of stress ulceration (1,2). Decreased gastric ph, increased mucosal permeability, and alterations in normal protective mechanisms may also be contributing factors (2,3). There has been a decrease in the incidence of clinically important bleeding due to stress ulceration (1). This can likely be attributed to improved resuscitation, earlier initiation of enteral feeding, the cessation of high dose steroids for traumatic brain and spinal cord injury, and possibly the use of pharmacologic prophylaxis. Medications used for stress ulcer prophylaxis act by inhibiting gastric acid secretion, neutralizing gastric acid, or protecting the gastric mucosa. The efficacy of H2RAs and antacids has been extensively studied. Both placebo-controlled trials and meta-analyses, however, have yielded conflicting results (2). Similarly, PPIs for stress ulcer prophylaxis have been evaluated in a limited number of published trials. Although these agents effectively maintain gastric ph 4, this endpoint has not been proven to improve clinical outcome. Additionally, superiority over H2RAs has not been demonstrated in a well-designed trial. Many investigators now question the value of pharmacologic prophylaxis, especially in the setting of improved resuscitation techniques and early enteral feeding. A randomized, controlled trial that compared a PPI, H2RA, and sucralfate with placebo in 287 high-risk trauma/surgery patients demonstrated no difference in clinically significant upper GI bleeding with percentages of 1%, 3%, 4%, and 1%, respectively (4). Prophylactic medications are associated with potential adverse effects such as increased risk of Clostridium difficile infection and ventilator associated pneumonia, and drug interactions as well as additional cost. LITERATURE REVIEW Risk Factors for Stress Ulceration In a multicenter study of 2252 patients, Cook et al. identified respiratory failure (mechanical ventilation for at least 24 hours) and coagulopathy (platelet count <50,000 mm 3, INR >1.5, or aptt > 2 times control) as independent risk factors for bleeding (5). Of the 33 patients (1.5%) with clinically important bleeding, 23 (70%) were receiving stress ulcer prophylaxis. However, the use of prophylaxis was not controlled and various regimens were administered. Enteral nutrition was not addressed. Only a small number of trauma patients were represented (28 head injuries and 18 multiple traumas). (Class II) A subsequent multivariate analysis by Cook et al. identified maximum serum creatinine as a risk factor (RR 1.16 [95% CI ]) for clinically important upper gastrointestinal bleeding (3). All patients received either ranitidine or sucralfate. The use of enteral feeding was not randomized. Enteral nutrition (RR 0.3 [95%CI ]) and ranitidine (RR 0.39 [95%CI ]) were both protective against stress ulceration. The overall incidence of clinically important gastrointestinal bleeding was 2.8%. None of the 147 trauma patients had clinically important bleeding. (Class II) Although other risk factors have been identified, they have not been well studied. These include sepsis, of intensive care unit (ICU) stay greater than one week, presence of occult bleeding for at least six days, and high dose corticosteroids (>250 mg/day hydrocortisone or equivalent) (2,6). There is evidence that the incidence of stress ulceration is higher when more than one risk factor is present (7). Patients suffering burn or neurologic injury have frequently been excluded from studies due to their presumably high-risk for the development of stress ulcers. Additional populations frequently excluded from clinical trials include patients with a history of upper gastrointestinal hemorrhage, peptic ulcer disease, or non-steroidal anti-inflammatory drug (NSAID) use. Whether these conditions translate into an increased risk of acute, stress-induced bleeding is therefore unknown (5). 2

3 Stress Ulceration and Enteral Feeding A meta-analysis published in 2010 included 17 randomized, controlled trials that enrolled a total of 1836 patients (8). This meta-analysis distinguished between studies that used early, adequate enteral nutrition from those that did not to assess the efficacy of stress ulcer prophylaxis. Results of the analysis demonstrated a reduced risk of GI bleeding with use of a H2RA only in the sub-group of patients that did not receive enteral nutrition. Stress ulcer prophylaxis did not decrease the risk for GI bleeding in the patients that were fed enterally. Although prophylaxis with H2RAs had no effect on pneumonia and hospital mortality overall, there was an increase in the incidence of hospital-acquired pneumonia and hospital mortality in the subgroup of patients that received stress ulcer prophylaxis plus enteral feeds. (Class II) In 2016, prospectively gathered data from 200 patients admitted to a single academic surgical/trauma ICU was analyzed for the risk of bleeding and the efficacy of their practice of discontinuing pharmacologic stress ulcer prophylaxis in patients tolerating full enteral nutrition (9). They found an overall incidence of 0.5% of clinically significant GI bleeding, with the subset of traumatic brain injury patients at only 0.68%, drastically different than the previously reported rate of 1.5%. Combined with the findings of a small randomized controlled, double blind, exploratory study enrolling 102 critically ill, mechanically ventilated patients that revealed no benefit (or harm) to adding pantoprazole to enteral nutrition (10), full enteral nutrition is probably adequate prophylaxis for stress ulcer prophylaxis in most critically ill patients. (Class II) Proton Pump Inhibitors (PPIs) Phillips et al. performed a prospective, open-label trial evaluating the efficacy of omeprazole suspension for stress ulcer prophylaxis in 75 critically ill patients (11). Patients were considered for the study if they were admitted to the surgical or burn ICU with an intact stomach, a nasogastric tube, and an anticipated ICU length of stay > 48 hours. They also had to have a gastric ph < 4, be on mechanical ventilation, and have an additional risk factor for stress ulceration. Patients were excluded if they were receiving enteral feedings through the nasogastric tube. Omeprazole suspension was administered as 40 mg, followed by a second 40 mg dose 6 to 8 hours later, then 20 mg daily until there was no longer a need for stress ulcer prophylaxis. Ten patients received H2RAs prior to omeprazole suspension. Of the 65 patients who received omeprazole suspension as their initial prophylaxis, none developed overt or clinically significant upper gastrointestinal bleeding. Omeprazole significantly increased the mean gastric ph within 4 hours of the start of therapy (3.5 to 7.1). (Class II) In a similar study, the efficacy of omeprazole suspension was evaluated in 66 patients with severe trauma (12). In addition to mechanical ventilation, patients were required to have at least one other risk factor for stress ulceration. Patients were excluded if they were receiving gastric feedings. Omeprazole was administered as described in the previous study. None of the patients developed overt or clinically significant upper gastrointestinal bleeding. Gastric ph monitoring revealed a statistically significant increase following initiation of omeprazole therapy (3 patients required an increased dose to achieve adequate ph control). (Class II) Levy et al. compared the efficacy of omeprazole versus ranitidine for prophylaxis against clinically important gastrointestinal hemorrhage in 67 patients admitted to an ICU who had at least one risk factor for stress ulceration (13). Patients were randomized to receive ranitidine (50 mg bolus followed by 150 mg daily by continuous infusion or intermittent administration) or omeprazole (40 mg daily orally or via nasogastric tube). Clinically important bleeding occurred in significantly more ranitidine patients compared to omeprazole patients (31% versus 6%; p=0.013). It should be noted that the ranitidine patients had significantly more risk factors for stress ulceration than the omeprazole patients did. The use of enteral nutrition was not addressed. (Class I) A meta-analysis was performed pooling 936 patients from seven randomized, controlled trials to compare the efficacy and safety of H2RAs to PPIs for stress ulcer prophylaxis (14). There was no statistically significant difference found in the incidence of upper gastrointestinal bleeding between PPIs and H2RAs. 3

4 In addition, no significant difference was found in the safety outcomes of pneumonia and ICU mortality. (Class II). More recently, a randomized, double blind exploratory study out of Australia with the acronym POP-UP (Pantoprazole Or Placebo for stress Ulcer Prophylaxis: randomized double-blind exploratory study) in 2016 suggested that, in 214 mechanically ventilated patients, pantoprazole did not decrease bleeding events, nor did it increase the risk of ventilator associated pneumonias or Clostridium difficile infections (15). A similar study in 2017 of 91 patients randomized to pantoprazole or placebo from 10 ICUs in Canada and Australia found no statistically significant differences, but trends towards decreased ventilator associated pneumonias and Clostridium difficile infections in the placebo group (16). These two studies, and multiple pending pilot studies, suggest that with current critical care practices and modern incidences of stress ulcerative bleeding, the traditional decision to routinely give acid suppression therapy to ICU patients should be carefully studied and reconsidered. Sucralfate Sucralfate is a molecular complex of sucrose, sulfate, and aluminum that is thought to form a protective barrier on the mucosal surface of the stomach, decreasing acid s erosive effect. It has been historically used as an adjunct to PPI and H2RA in refractory ulcerative GI bleeding or in patients intolerant to these medications. In 2016, Gindlinger et al. performed a retrospective study after perceiving an association between ventilator acquired pneumonia and ventilator bundle compliance (17). Their bundle elements included stress ulcer prophylaxis, head of bed elevation to 30º, daily sedation vacation, and deep-venous thrombosis prophylaxis, similar to the 2005 study by Rezar (18) that saw ventilator acquired pneumonias decrease by 45%. They retrospectively reviewed 504 patients and evaluated those receiving sucralfate as stress ulcer prophylaxis versus pantoprazole, omeprazole, or famotidine. In the PPI/H2RA group, they found 10.2 ventilator associated pneumonias per 1000 ventilator days versus 3.7 ventilator associated pneumonias per 1000 ventilator days in the sucralfate group. Furthermore, the type of pneumonia contracted was significantly different, with the sucralfate group incurring oropharyngeal flora bacteria compared with gram negative rods, methicillin resistant Staphylococcus aureus and Pseudomonas in the PPI/H2RA group. These initial data suggest a promising role for sucralfate as stress ulcer prophylaxis in at risk patients. REFERENCES 1. Barletta JF, Mangram AJ, Sucher JF, and Zach V. Stress ulcer prophylaxis in neurocritical care. Neurocrit Care, September American Society of Health-System Pharmacists. ASHP therapeutic guidelines on stress ulcer prophylaxis. Am J Health-Sys Pharm 1999; 56: Cook D, Heyland D, Griffith L, et al. Risk factors for clinically important upper gastrointestinal bleeding in patients requiring mechanical ventilation. Crit Care Med 1999; 27: Kantorova I, Svoboda P, Scheer P, et al. Stress ulcer prophylaxis in critically ill patients: a randomized controlled trial. Hepato-Gastroenterology 2004; 51: Cook DJ, Fuller HD, Guyatt GH, et al. Risk factors for gastrointestinal bleeding in critically ill patients. N Engl J Med 1994; 330: Sasabuchi Y, et al. Risks and benefits of stress ulcer prophylaxis for patients with severe sepsis. Journal of Critical Care Medicine. July 2016, Vol 44:7. 7. Metz CA, Livingston DH, Smith S, et al. Impact of multiple risk factors and ranitidine prophylaxis on the development of stress-related upper gastrointestinal bleeding: A prospective, multicenter, doubleblind, randomized trial. Crit Care Med 1993; 21: Marik P, Vasu T, Hirani A, et al. Stress ulcer prophylaxis in the new millennium: A systematic review and meta-analysis. Crit Care Med 2010; 38: Palm NM, et al. Pharmacologic stress gastropathy prophylaxis may not be necessary in at-risksurgical trauma ICU patients tolerating enteral nutrition. J Intens Care Med, Oct

5 10. El-Kersh K, et al. Enteral nutrition as stress ulcer prophylaxis in critically ill patients: a randomized controlled exploratory study. J Crit Care. 43, 2018, Phillips JO, Metzler MH, Palmieri TL, et al. A prospective study of simplified omeprazole suspension for the prophylaxis of stress-related mucosal damage. Crit Care Med 1996; 24: Lasky MR, Metzler MH, Phillips JO. A prospective study of omeprazole suspension to prevent clinically significant gastrointestinal bleeding from stress ulcers in mechanically ventilated trauma patients. J Trauma 1998; 44: Levy MJ, Seelig CB, Robinson NJ, et al. Comparison of omeprazole and ranitidine for stress ulcer prophylaxis. Dig Dis Sci 1997; 42: Lin PC, Chang CH, Hsu PI, et al. The efficacy and safety of proton pump inhibitors vs histamine-2 receptor antagonists for stress ulcer prophylaxis among critical care patients: A meta-analysis. Crit Care Med 2010; 38: Selvanderan SP, et al. Pantoprazole or placebo for stress ulcer prophylaxis (POP-UP): randomized double-blind exploratory study. Crit Care Med, Oct : Alhazzani W, et al. Withholding pantoprazole for stress ulcer prophylaxis in critically ill patients: a pilot randomized clinical trial and meta-analysis. Crit Care Med, July 2017, 45: Grindling GA, Cairo SB, and Duperre CB. Pneumonia prevention in intubated patients given sucralfate versus proton-pump inhibitors and/or histamine II receptor blockers. J Surg Research, December 2016, 206. P Rezar, R, Pronovost P, Haraden C, et al. Using a bundle approach to improve ventilator care processed and reduce ventilator associated pneumonia. Jt Comm J Qual Patient Saf. 2005; 31: Surgical Critical Care Evidence-Based Medicine Guidelines Committee Primary Author: Nathan Smith, MD Editors: Michael L. Cheatham, MD, Chadwick Smith, MD Last revision date: November 2, 2017 Please direct any questions or concerns to: webmaster@surgicalcriticalcare.net 5

6 STRESS ULCER PROPHYLAXIS Consider Stress Ulcer Prophylaxis NO Are any acute risk factors present? No Therapy Indicated YES Observe patient for development of risk factors Does patient have evidence of stress ulceration? YES Initiate parenteral proton pump inhibitor NO Is patient on home proton pump inhibitor therapy? YES Initiate enteral or parenteral proton pump inhibitor NO Initiate enteral or parenteral H 2 RA therapy or sucralfate Observe patient for stress ulceration Enteral therapy should be used whenever a functioning gastrointestinal tract is present and adequate absorption can be assumed. Sucralfate is an acceptable substitute for H 2 RA therapy if: 1) No drug interactions are present (i.e., use of quinolones or levothyroxine) AND 2) Gastric access is available 6

Stressed Out: Evaluating the Need for Stress Ulcer Prophylaxis in the ICU

Stressed Out: Evaluating the Need for Stress Ulcer Prophylaxis in the ICU Stressed Out: Evaluating the Need for Stress Ulcer Prophylaxis in the ICU Josh Arnold, PharmD PGY1 Pharmacy Resident Pharmacy Grand Rounds November 8, 2016 2016 MFMER slide-1 Objectives Identify the significance

More information

Audit: Use of stress ulcer prophylaxis in critically ill patients

Audit: Use of stress ulcer prophylaxis in critically ill patients Audit: Use of stress ulcer prophylaxis in critically ill patients Dr. Sinan Bahlool Consultant, Anaesthetics & ITU Dr. Krushna Patel FY1 Dr. Andrew Baigey FY1 BACKGROUND Stress ulcer prophylaxis is prescribed

More information

Optimal Drugs for ICU Stress Ulcer Prophylaxis: Other. Grand Rounds Monday August 9, 2010 Teresa Jones R2

Optimal Drugs for ICU Stress Ulcer Prophylaxis: Other. Grand Rounds Monday August 9, 2010 Teresa Jones R2 Optimal Drugs for ICU Stress Ulcer Prophylaxis: Other Grand Rounds Monday August 9, 2010 Teresa Jones R2 Outline Options besides PPIs Comparison to PPIs Negative Effects of PPIs Conclusion Do we really

More information

Proton Pump Inhibitors- Questions & Controversies. Farah Kablaoui, PharmD, BCPS, BCCCP

Proton Pump Inhibitors- Questions & Controversies. Farah Kablaoui, PharmD, BCPS, BCCCP Proton Pump Inhibitors- Questions & Controversies Farah Kablaoui, PharmD, BCPS, BCCCP Disclosure Information Proton Pump Inhibitors: Questions & Controversies Farah Kablaoui I have no financial relationship

More information

Do PPIs Reduce Bleeding in ICU? Revisiting Stress Ulcer Prophylaxis. Deborah Cook

Do PPIs Reduce Bleeding in ICU? Revisiting Stress Ulcer Prophylaxis. Deborah Cook Do PPIs Reduce Bleeding in ICU? Revisiting Stress Ulcer Prophylaxis Deborah Cook ICU-Acquired Upper GI Bleeding Case series of 300 ICU patients describing stressrelated erosive syndrome Frequent Fatal

More information

Chapter 34. Prevention of Clinically Significant Gastrointestinal Bleeding in Intensive Care Unit Patients

Chapter 34. Prevention of Clinically Significant Gastrointestinal Bleeding in Intensive Care Unit Patients Chapter 34. Prevention of Clinically Significant Gastrointestinal Bleeding in Intensive Care Unit Patients Daniel D. Dressler, MD Mark V. Williams, MD Kimberly Rask, MD, PhD Emory University Schools of

More information

VUMC Multidisciplinary Surgical Critical Care

VUMC Multidisciplinary Surgical Critical Care VUMC Multidisciplinary Surgical Critical Care Gastrointestinal Stress Ulcer Prophylaxis Guideline: Background: Work by Cooke and colleagues ascribed the risk of overt bleeding to be 4.4% and clinically

More information

Stress Ulcer Prophylaxis In The ICU. Scott W. Wolf Anesthesiology Critical Care Medicine

Stress Ulcer Prophylaxis In The ICU. Scott W. Wolf Anesthesiology Critical Care Medicine Stress Ulcer Prophylaxis In The ICU Scott W. Wolf Anesthesiology Critical Care Medicine Some history Stress Ulceration described in ICU patients as long as 45 years ago Patients had a constellation of

More information

GASTROINTESTINAL AND ANTIEMETIC DRUGS. Submitted by: Shaema M. Ali

GASTROINTESTINAL AND ANTIEMETIC DRUGS. Submitted by: Shaema M. Ali GASTROINTESTINAL AND ANTIEMETIC DRUGS Submitted by: Shaema M. Ali GASTROINTESTINAL AND ANTIEMETIC DRUGS by: Shaema M. Ali There are four common medical conditions involving the GI system 1) peptic ulcers

More information

Appropriate Use of Proton Pump Inhibitors (PPIs) Anderson Mabour, Pharm.D., BCPS Clinical Pharmacy Specialist

Appropriate Use of Proton Pump Inhibitors (PPIs) Anderson Mabour, Pharm.D., BCPS Clinical Pharmacy Specialist Appropriate Use of Proton Pump Inhibitors (PPIs) Anderson Mabour, Pharm.D., BCPS Clinical Pharmacy Specialist Disclosures I have no actual or potential conflicts of interest to report in relation to this

More information

VAP Prevention bundles

VAP Prevention bundles VAP Prevention bundles Dr. Shafiq A.Alimad MD Head of medical department at USTH YICID workshop, 15-12-2014 Care Bundles What are they & why use them? What are Care Bundles? Types of Care Bundles available

More information

Evidence-Based. Management of Severe Sepsis. What is the BP Target?

Evidence-Based. Management of Severe Sepsis. What is the BP Target? Evidence-Based Management of Severe Sepsis Michael A. Gropper, MD, PhD Professor and Vice Chair of Anesthesia Director, Critical Care Medicine Chair, Quality Improvment University of California San Francisco

More information

Ehab Abdel-Khalek, M.D.

Ehab Abdel-Khalek, M.D. Gastrointestinal prophylaxis in critically ill patients Ehab Abdel-Khalek, M.D. Professor of Hepatology and Gastroenterology, Faculty of Medicine, Mansoura University Conflict of Interest I did not receive

More information

Prevention of Complications in Hospitalized Patients Part III: Upper Gastrointestinal Stress Ulcers

Prevention of Complications in Hospitalized Patients Part III: Upper Gastrointestinal Stress Ulcers CLINICAL REVIEW Prevention of Complications in Hospitalized Patients Part III: Upper Gastrointestinal Stress Ulcers Michael A. Pfeffer, M.D., and Michael S. Galindo, M.D. The Clinical Scenario A 70-year-old

More information

ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis

ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis A SHP REPORT Stress ulcer prophylaxis ASHP Report ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis DEVELOPED THROUGH THE ASHP COMMISSION ON THERAPEUTICS AND APPROVED BY THE ASHP BOARD OF DIRECTORS

More information

Proton Pump Inhibitors:

Proton Pump Inhibitors: Proton Pump Inhibitors: How bad could they be? Andrea Flanagan, Pharm.D. Iowa City VA Medical Center PGY-1 Pharmacy Resident Objectives for Pharmacists At the end of this presentation PHARMACISTS should

More information

SELECTED ABSTRACTS. Figure. Risk Stratification Matrix A CLINICIAN S GUIDE TO THE SELECTION OF NSAID THERAPY

SELECTED ABSTRACTS. Figure. Risk Stratification Matrix A CLINICIAN S GUIDE TO THE SELECTION OF NSAID THERAPY SELECTED ABSTRACTS A CLINICIAN S GUIDE TO THE SELECTION OF NSAID THERAPY The authors of this article present a 4-quadrant matrix based on 2 key clinical parameters: risk for adverse gastrointestinal (GI)

More information

Anticoagulants are a contributing factor. Other causes are Mallory-Weiss tears, AV malformations, and malignancy and aorto-enteric fistula.

Anticoagulants are a contributing factor. Other causes are Mallory-Weiss tears, AV malformations, and malignancy and aorto-enteric fistula. Upper GI Bleeding EMU2018 Dr. Walter Himmel MD Incidence: In non-cirrhotics, the commonest causes are peptic ulcer disease (50%) followed by erosive gastritis. In cirrhotic patients, variceal bleeding

More information

Gastroduodenal Stress Ulceration. Bryan Woolridge POS Rounds 29 October 2003

Gastroduodenal Stress Ulceration. Bryan Woolridge POS Rounds 29 October 2003 Gastroduodenal Stress Ulceration Bryan Woolridge POS Rounds 29 October 2003 Objectives Define entity Etiology Differentiation of UGI ulcers Pathophysiology Identify population at risk/risk factors Clinical

More information

Helicobacter pylori. Objectives. Upper Gastrointestinal Bleeding Peptic Ulcer Disease

Helicobacter pylori. Objectives. Upper Gastrointestinal Bleeding Peptic Ulcer Disease Upper Gastrointestinal Bleeding Peptic Ulcer Disease Pharmacotherapy Issues in Acute Management and Secondary Prevention Peter J. Zed, B.Sc., B.Sc.(Pharm), Pharm.D. Pharmacotherapeutic Specialist - Emergency

More information

ACUTE UPPER GASTROINTESTINAL HEMORRHAGE: PHARMACOLOGIC MANAGEMENT

ACUTE UPPER GASTROINTESTINAL HEMORRHAGE: PHARMACOLOGIC MANAGEMENT DISCLAIMER: These guidelines were prepared by the Department of Surgical Education, Orlando Regional Medical Center. They are intended to serve as a general statement regarding appropriate patient care

More information

Hospital-Acquired Gastrointestinal Bleeding Outside the Critical Care Unit. Risk Factors, Role of Acid Suppression, and Endoscopy Findings

Hospital-Acquired Gastrointestinal Bleeding Outside the Critical Care Unit. Risk Factors, Role of Acid Suppression, and Endoscopy Findings ORIGINAL RESEARCH Hospital-Acquired Gastrointestinal Bleeding Outside the Critical Care Unit Risk Factors, Role of Acid Suppression, and Endoscopy Findings Mohammed A. Qadeer, MD 1 Joel E. Richter, MD

More information

A. Incorrect! Histamine is a secretagogue for stomach acid, but this is not the only correct answer.

A. Incorrect! Histamine is a secretagogue for stomach acid, but this is not the only correct answer. Pharmacology - Problem Drill 21: Drugs Used To Treat GI Disorders No. 1 of 10 1. Endogenous secretagogues for stomach acid include: #01 (A) Histamine (B) Gastrin (C) PGE1 (D) A and B (E) A, B and C Histamine

More information

LONG -TERM USE OF PPIS: INDICATIONS, BENEFITS AND HARMS. Jihane Naous, M.D.

LONG -TERM USE OF PPIS: INDICATIONS, BENEFITS AND HARMS. Jihane Naous, M.D. LONG -TERM USE OF PPIS: INDICATIONS, BENEFITS AND HARMS Jihane Naous, M.D. Objectives Identify the conditions supported by AGA/ACG guidelines necessitating long-term use of daily PPIs, Recognize which

More information

Oral proton pump inhibitors (PPIs)

Oral proton pump inhibitors (PPIs) Treatment Guideline Oral proton pump inhibitors (PPIs) Introduction The high efficacy and low toxicity of proton pump inhibitors (PPIs) has contributed to their frequent prescription worldwide, often without

More information

FLUID RESUSCITATION SUMMARY

FLUID RESUSCITATION SUMMARY DISCLAIMER: These guidelines were prepared by the Department of Surgical Education, Orlando Regional Medical Center. They are intended to serve as a general statement regarding appropriate patient care

More information

Current Concepts in VAP: Stress Ulcer Prophylaxis & Probiotics. Deborah Cook

Current Concepts in VAP: Stress Ulcer Prophylaxis & Probiotics. Deborah Cook Current Concepts in VAP: Stress Ulcer Prophylaxis & Probiotics Deborah Cook Objectives VAP The Old: Gastropulmonary route of infection The New: Microbiome modification Role of acid suppression Influence

More information

MANAGEMENT OF DYSPEPSIA AND GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)

MANAGEMENT OF DYSPEPSIA AND GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD) DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT OF DYSPEPSIA AND GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD) Routine endoscopic investigation of patients of any age, presenting with dyspepsia

More information

Opinions and practice of stress ulcer prophylaxis in Australian and New Zealand intensive care units

Opinions and practice of stress ulcer prophylaxis in Australian and New Zealand intensive care units Opinions and practice of stress ulcer prophylaxis in Australian and New Zealand intensive care units Glenn M Eastwood, Ed Litton, Rinaldo Bellomo, Michael J Bailey, Mario Festa, Richard W Beasley and Paul

More information

Pantoprazole or Placebo for Stress Ulcer Prophylaxis (POP-UP): Randomized Double-Blind Exploratory Study*

Pantoprazole or Placebo for Stress Ulcer Prophylaxis (POP-UP): Randomized Double-Blind Exploratory Study* or for Stress Ulcer Prophylaxis (POP-UP): Randomized Double-Blind Exploratory Study* Shane P. Selvanderan, BMEdSci (Hon), MBBS 1 ; Matthew J. Summers, BSc, MDiet 2 ; Mark E. Finnis, MBBS, MBiostat 1,2

More information

SEPSIS: IT ALL BEGINS WITH INFECTION. Theresa Posani, MS, RN, ACNS-BC, CCRN M/S CNS/Sepsis Coordinator Texas Health Harris Methodist Ft.

SEPSIS: IT ALL BEGINS WITH INFECTION. Theresa Posani, MS, RN, ACNS-BC, CCRN M/S CNS/Sepsis Coordinator Texas Health Harris Methodist Ft. SEPSIS: IT ALL BEGINS WITH INFECTION Theresa Posani, MS, RN, ACNS-BC, CCRN M/S CNS/Sepsis Coordinator Texas Health Harris Methodist Ft. Worth 1 2 3 OBJECTIVES Review the new Sepsis 3 definitions of sepsis

More information

The presence and development of gastric ulcers. Evaluation of Stress Ulcer Prophylaxis in a Family Medicine Residency Inpatient Service

The presence and development of gastric ulcers. Evaluation of Stress Ulcer Prophylaxis in a Family Medicine Residency Inpatient Service Evaluation of Stress Ulcer Prophylaxis in a Family Medicine Residency Inpatient Service Heather A. Kehr, PharmD, BCPS, Carrie L. Griffiths, PharmD, R. Wesley Haynes, PharmD, Sonia Everhart, PharmD, BCPS,

More information

GI Pharmacology. Dr. Alia Shatanawi 5/4/2018

GI Pharmacology. Dr. Alia Shatanawi 5/4/2018 GI Pharmacology Dr. Alia Shatanawi 5/4/2018 Drugs Used in Gastrointestinal Diseases Drugs used in Peptic Ulcer Diseases. Drugs Stimulating Gastrointestinal Motility &Laxatives. Antidiarrheal Agents. Drugs

More information

In 1970, Skillman and Silen (1) reported a clinical syndrome

In 1970, Skillman and Silen (1) reported a clinical syndrome Feature Articles Proton Pump Inhibitors Versus Histamine 2 Receptor Antagonists for Stress Ulcer Prophylaxis in Critically Ill Patients: A Systematic Review and Meta-Analysis* Waleed Alhazzani, MD 1 ;

More information

Am J Gastroenterol 2010;105:

Am J Gastroenterol 2010;105: ACCF/ACG/AHA 2010 Expert Consensus Document Expert Consensus Document on the Concomitant Use of Proton Pump Inhibitors and Thienopyridines: A Focused Update of the ACCF/ACG/AHA 2008 Expert Consensus Document

More information

Famotidine Extended Abstracts

Famotidine Extended Abstracts Famotidine Extended Abstracts I) Primary literature Summary Ciccone, Decktor, et. al. Efficacy and tolerability of famotidine in preventing heartburn and related symptoms of upper gastrointestinal discomfort.

More information

Lies, damn lies, & clinical trials. Paul Young

Lies, damn lies, & clinical trials. Paul Young Lies, damn lies, & clinical trials Paul Young Base rate neglect statistical power probability of detecting a difference if one exists P of

More information

Peptic ulcer disease Disorders of the esophagus

Peptic ulcer disease Disorders of the esophagus Peptic ulcer disease Disorders of the esophagus Peptic ulcer disease Burning epigastric pain Exacerbated by fasting Improved with meals Ulcer: disruption of mucosal integrity >5 mm in size, with depth

More information

4/5/2018. Update on Sepsis NIKHIL JAGAN PULMONARY AND CRITICAL CARE CREIGHTON UNIVERSITY. I have no financial disclosures

4/5/2018. Update on Sepsis NIKHIL JAGAN PULMONARY AND CRITICAL CARE CREIGHTON UNIVERSITY. I have no financial disclosures Update on Sepsis NIKHIL JAGAN PULMONARY AND CRITICAL CARE CREIGHTON UNIVERSITY I have no financial disclosures 1 Objectives Why do we care about sepsis Understanding the core measures by Centers for Medicare

More information

FARMACI E ALTE VIE DIGESTIVE NELL ANZIANO: UTILITÀ E LIMITI

FARMACI E ALTE VIE DIGESTIVE NELL ANZIANO: UTILITÀ E LIMITI FARMACI E ALTE VIE DIGESTIVE NELL ANZIANO: UTILITÀ E LIMITI Edoardo V. Savarino, MD, PhD Professor of Gastroenterology Department of Surgery, Oncology and Gastroenterology University of Padua Italy COMMON

More information

CHAPTER 18. PEPTIC ULCER DISEASE, SELF-ASSESSMENT QUESTIONS. 1. Which of the following is not a common cause of peptic ulcer disease (PUD)?

CHAPTER 18. PEPTIC ULCER DISEASE, SELF-ASSESSMENT QUESTIONS. 1. Which of the following is not a common cause of peptic ulcer disease (PUD)? CHAPTER 18. PEPTIC ULCER DISEASE, SELF-ASSESSMENT QUESTIONS 1. Which of the following is not a common cause of peptic ulcer disease (PUD)? A. Chronic alcohol ingestion B. Nonsteroidal antiinflammatory

More information

New Strategies in the Management of Patients with Severe Sepsis

New Strategies in the Management of Patients with Severe Sepsis New Strategies in the Management of Patients with Severe Sepsis Michael Zgoda, MD, MBA President, Medical Staff Medical Director, ICU CMC-University, Charlotte, NC Factors of increases in the dx. of severe

More information

USE OF FOSPHENYTOIN (CEREBYX ) AND INTRAVENOUS PHENYTOIN (DILANTIN ) IN ADULT PATIENTS

USE OF FOSPHENYTOIN (CEREBYX ) AND INTRAVENOUS PHENYTOIN (DILANTIN ) IN ADULT PATIENTS DISCLAIMER: These guidelines were prepared by the Department of Surgical Education, Orlando Regional Medical Center. They are intended to serve as a general statement regarding appropriate patient care

More information

The Appropriateness of Acid Suppressive Medications Use in a Tertiary Hospital in Kedah

The Appropriateness of Acid Suppressive Medications Use in a Tertiary Hospital in Kedah Human Journals Research Article July 2016 Vol.:6, Issue:4 All rights are reserved by Kirubakaran Ranita et al. The Appropriateness of Acid Suppressive Medications Use in a Tertiary Hospital in Kedah Keywords:

More information

Policy Evaluation: Proton Pump Inhibitors (PPIs)

Policy Evaluation: Proton Pump Inhibitors (PPIs) Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35 Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119

More information

Updates to pharmacological management in the prevention of recurrent Clostridium difficile

Updates to pharmacological management in the prevention of recurrent Clostridium difficile Updates to pharmacological management in the prevention of recurrent Clostridium difficile Julia Shlensky, PharmD PGY2 Internal Medicine Resident September 12, 2017 2017 MFMER slide-1 Clinical Impact Increasing

More information

Preventing Ventilator-Associated Pneumonia: Five Components of Care

Preventing Ventilator-Associated Pneumonia: Five Components of Care Institute for Healthcare Improvement Preventing Ventilator-Associated Pneumonia: Five Components of Care 1. Elevation of the Head of the Bed Elevation of the head of the bed is an integral part of the

More information

Crit Vent Bundle for Mechanical Ventilation (337) [337] Physician - Also, enter Critical Care Admission Orders

Crit Vent Bundle for Mechanical Ventilation (337) [337] Physician - Also, enter Critical Care Admission Orders Crit Vent Bundle for Mechanical Ventilation (337) [337] Physician - Also, enter Critical Care Admission Orders Initial Vent Settings (Single Response) [6360] If no previous orders and no choice made by

More information

Proton Pump Inhibitors. Description. Section: Prescription Drugs Effective Date: July 1, 2014

Proton Pump Inhibitors. Description. Section: Prescription Drugs Effective Date: July 1, 2014 Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.09.01 Subject: Proton Pump Inhibitors Page: 1 of 7 Last Review Date: June 12, 2014 Proton Pump Inhibitors

More information

Scottish Medicines Consortium

Scottish Medicines Consortium Scottish Medicines Consortium esomeprazole, 40mg vial of powder for solution for intravenous injection or infusion (Nexium I.V. ) No. (578/09) AstraZeneca 09 October 2009 The Scottish Medicines Consortium

More information

All Indiana Medicaid Prescribers and Pharmacy Providers

All Indiana Medicaid Prescribers and Pharmacy Providers P R O V I D E R B U L L E T I N BT200148 NOVEMBER 28, 2001 To: All Indiana Medicaid Prescribers and Pharmacy Providers Subject: Note: The information in this bulletin regarding prior authorization payment

More information

Part 2 of park s Ventilator and ARDS slides for syllabus

Part 2 of park s Ventilator and ARDS slides for syllabus Part 2 of park s Ventilator and ARDS slides for syllabus Early Neuromuscular Blockade Question 4 The early use of cis-atracurium in severe ARDS is: A. Contraindicated in patients with diabetes B. Associated

More information

COMPARISON OF ONCE-A-DAY VERSUS TWICE-A-DAY CLARITHROMYCIN IN TRIPLE THERAPY FOR HELICOBACTER PYLORI ERADICATION

COMPARISON OF ONCE-A-DAY VERSUS TWICE-A-DAY CLARITHROMYCIN IN TRIPLE THERAPY FOR HELICOBACTER PYLORI ERADICATION Phil J Gastroenterol 2006; 2: 25-29 COMPARISON OF ONCE-A-DAY VERSUS TWICE-A-DAY CLARITHROMYCIN IN TRIPLE THERAPY FOR HELICOBACTER PYLORI ERADICATION Marianne P Collado, Ma Fatima P Calida, Peter P Sy,

More information

Surviving Sepsis Campaign. Guidelines for Management of Severe Sepsis/Septic Shock. An Overview

Surviving Sepsis Campaign. Guidelines for Management of Severe Sepsis/Septic Shock. An Overview Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis/Septic Shock An Overview Mechanical Ventilation of Sepsis-Induced ALI/ARDS ARDSnet Mechanical Ventilation Protocol Results: Mortality

More information

Steroid in Paediatric Sepsis. Dr Pon Kah Min Hospital Pulau Pinang

Steroid in Paediatric Sepsis. Dr Pon Kah Min Hospital Pulau Pinang Steroid in Paediatric Sepsis Dr Pon Kah Min Hospital Pulau Pinang Contents Importance of steroid in sepsis Literature Review for adult studies Literature Review for paediatric studies Conclusions. Rationale

More information

Septic shock. Babak Tamizi Far M.D Isfahan university of medical sciences

Septic shock. Babak Tamizi Far M.D Isfahan university of medical sciences Septic shock Babak Tamizi Far M.D Isfahan university of medical sciences Definitions Used to Describe the Condition of Septic Patients Approximately 750,000 cases of severe sepsis or septic shock occur

More information

See Important Reminder at the end of this policy for important regulatory and legal information.

See Important Reminder at the end of this policy for important regulatory and legal information. Clinical Policy: (Duexis) Reference Number: CP.PMN.120 Effective Date: 06.01.18 Last Review Date: 05.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of this policy

More information

Back to the Future: Updated Guidelines for Evaluation and Management of Adrenal Insufficiency in the Critically Ill

Back to the Future: Updated Guidelines for Evaluation and Management of Adrenal Insufficiency in the Critically Ill Back to the Future: Updated Guidelines for Evaluation and Management of Adrenal Insufficiency in the Critically Ill Joe Palumbo PGY-2 Critical Care Pharmacy Resident Buffalo General Medical Center Disclosures

More information

The usual dose is 40 mg daily with amoxycillin 1.5 g (750 mg b.d.) for 2 weeks. Up to 2 g/day of amoxycillin has been used in clinical trials.

The usual dose is 40 mg daily with amoxycillin 1.5 g (750 mg b.d.) for 2 weeks. Up to 2 g/day of amoxycillin has been used in clinical trials. Name Gasec - 2 Gastrocaps Composition Gasec-20 Gastrocaps Each Gastrocaps contains: Omeprazole 20 mg (in the form of enteric-coated pellets) Properties, effects Proton Pump Inhibitor Omeprazole belongs

More information

COMPUS OPTIMAL THERAPY REPORT. Supporting Informed Decisions. À l appui des décisions éclairées

COMPUS OPTIMAL THERAPY REPORT. Supporting Informed Decisions. À l appui des décisions éclairées OPTIMAL THERAPY REPORT COMPUS Volume 1, Issue 6 March 2007 Gap Analysis Report for the Prescribing and Use of Proton Pump Inhibitors (PPIs) Supporting Informed Decisions À l appui des décisions éclairées

More information

5.3 Strategies to Optimize Delivery and Minimize Risks of EN: Small Bowel Feeding vs. Gastric February 2014

5.3 Strategies to Optimize Delivery and Minimize Risks of EN: Small Bowel Feeding vs. Gastric February 2014 5.3 Strategies to Optimize Delivery and Minimize Risks of EN: Small Bowel Feeding vs. Gastric February 2014 2013 Recommendation: Based on 15 level 2 studies, small bowel feeding compared to gastric feeding

More information

a newsletter detailing appropriate indications of IV PPI was sent to physicians;

a newsletter detailing appropriate indications of IV PPI was sent to physicians; Inappropriate use of intravenous pantoprazole: extent of the problem and successful solutions Kaplan G G, Bates D, McDonald D, Panaccione R, Romagnuolo J Record Status This is a critical abstract of an

More information

Submitted: 14 Sep 2018; Accepted: 24 Sep 2018; Published: 24 Oct 2018

Submitted: 14 Sep 2018; Accepted: 24 Sep 2018; Published: 24 Oct 2018 Research Article Oral Ppi VS IV Ppi in Hospitalized Patient Hallal Mahmoud* and Rasha Matar Journal of Gastroenterology & Digestive Systems Department of Gastroenterology and Hepatology, AlZahraa University

More information

Identifying patients who may benefit from stepping down PPI treatment

Identifying patients who may benefit from stepping down PPI treatment CLINICAL AUDIT Identifying patients who may benefit from stepping down PPI treatment Valid to January 2024 bpac nz better medicin e This audit identifies patients who are prescribed the proton pump inhibitor

More information

Effective Health Care

Effective Health Care Effective Health Care Comparative Effectiveness of Management Strategies for Gastroesophageal Reflux Disease Executive Summary Background Gastroesophageal reflux disease (GERD), defined as weekly heartburn

More information

Key words: pharyngeal flora, gastric flora, enteral tube feeding, elderly patients, group B streptococci (GBS)

Key words: pharyngeal flora, gastric flora, enteral tube feeding, elderly patients, group B streptococci (GBS) Key words: pharyngeal flora, gastric flora, enteral tube feeding, elderly patients, group B streptococci (GBS) Table 1 Backgrounds of patients receiving nasogastric tube feeding Table 2 Bacteria isolated

More information

Proton Pump Inhibitor De-prescribing Guidance

Proton Pump Inhibitor De-prescribing Guidance Amendment History Proton Pump Inhibitor De-prescribing Guidance VERSION DATE AMENDMENT HISTORY 1.0 2013 Previous version 2.0 September 2015 Comments Amendment to Flow chart and addition of Rationale page

More information

11/19/2012. Comparison between PPIs G CELL. Risk ratio (95% CI) Patient subgroup. gastrin. S-form of omeprazole. Acid sensitive. coated.

11/19/2012. Comparison between PPIs G CELL. Risk ratio (95% CI) Patient subgroup. gastrin. S-form of omeprazole. Acid sensitive. coated. REGULATION OF GASTRIC ACID SECRETION Comparison between PPIs Omeprazole Lansoprazole Rabeprazole Pantoprazole Esomeprazole gastrin G CELL + Acid sensitive Yes T1/2 30-60 minutes Main elimination Enteric

More information

NSAIDs: Side Effects and Guidelines

NSAIDs: Side Effects and Guidelines NSAIDs: Side Effects and James J Hale FY1 Department of Anaesthetics Introduction The non-steroidal anti-inflammatory drugs (NSAIDs) are a diverse group of drugs that have analgesic, antipyretic and anti-inflammatory

More information

Steroids in ARDS: if, when, how much? John Fowler, MD, FACEP Dept. of Emergency Medicine Kent Hospital, İzmir, Türkiye

Steroids in ARDS: if, when, how much? John Fowler, MD, FACEP Dept. of Emergency Medicine Kent Hospital, İzmir, Türkiye Steroids in ARDS: if, when, how much? John Fowler, MD, FACEP Dept. of Emergency Medicine Kent Hospital, İzmir, Türkiye Steroids in ARDS: conclusion Give low-dose steroids if indicated for another problem

More information

Acetaminophen recommendations from the Food and Drug Administration Advisory Committee

Acetaminophen recommendations from the Food and Drug Administration Advisory Committee TABLE OF CONTENTS Acetaminophen: recommendations from the FDA Advisory Committee 1 Recombinant human erythropoiesis-stimulating agents and mortality in cancer patients Hospital-acquired pneumonia: risks

More information

Cytochrome P450 interactions

Cytochrome P450 interactions Cytochrome P450 interactions Learning objectives After completing this activity, pharmacists should be able to: Explain the mechanism of action of clopidogrel-ppi interaction Assess the risks and benefits

More information

Update in Hospital Medicine. Update in Hospital Medicine 2009

Update in Hospital Medicine. Update in Hospital Medicine 2009 2009 Bradley A. Sharpe, MD UCSF Division of Hospital Medicine PE in Acute COPD Exacerbations Question: What is the prevalence of PE in patients with COPD who need hospitalization? Design: Systematic review,

More information

Guidelines for the Management of Dyspepsia and GORD. Gastroenterology/ Acute Adult Governance. Drugs and Therapeutics Committee

Guidelines for the Management of Dyspepsia and GORD. Gastroenterology/ Acute Adult Governance. Drugs and Therapeutics Committee Guidelines for the Management of Dyspepsia and GORD Document type: Version: 3.0 Author (name): Author (designation): Validated by Prescribing Dr. G. Lipscomb Date validated October 2015 Ratified by: Date

More information

Original Investigation

Original Investigation Research Original Investigation Histamine-2 Receptor Antagonists vs Proton Pump Inhibitors on Gastrointestinal Tract Hemorrhage and Infectious Complications in the Intensive Care Unit Robert MacLaren,

More information

DELIRIUM IN ICU: Prevention and Management. Milind Baldi

DELIRIUM IN ICU: Prevention and Management. Milind Baldi DELIRIUM IN ICU: Prevention and Management Milind Baldi Contents Introduction Risk factors Assessment Prevention Management Introduction Delirium is a syndrome characterized by acute cerebral dysfunction

More information

Long-Term Care Updates

Long-Term Care Updates Long-Term Care Updates April 2017 Bezlotoxumab to Prevent Recurrent Infection By Amy Wilson, PharmD and Zara Risoldi Cochrane, PharmD, MS, FASCP Introduction The Gram-positive bacteria is a common cause

More information

Subclinical Problems in the ICU:

Subclinical Problems in the ICU: Subclinical Problems in the ICU: Corticosteroid Insufficiency C. S. Cutillar, M.D., FPCP, FPSEM Associate Professor Cebu Institute of Medicine H-P-A Axis during Critical Illness CRH ACTH H-P-A Axis during

More information

National Digestive Diseases Information Clearinghouse

National Digestive Diseases Information Clearinghouse Gastritis National Digestive Diseases Information Clearinghouse U.S. Department of Health and Human Services NATIONAL INSTITUTES OF HEALTH What is gastritis? Gastritis is a condition in which the stomach

More information

Pathophysiology and prophylaxis of stress ulcer in intensive care unit patients

Pathophysiology and prophylaxis of stress ulcer in intensive care unit patients Journal of Critical Care (2005) 20, 35 45 Pathophysiology and prophylaxis of stress ulcer in intensive care unit patients Neil Stollman MD a, *, David C. Metz MD b a Division of Gastroenterology, Department

More information

The following content was supplied by the author as supporting material and has not been copy-edited or verified by JBJS.

The following content was supplied by the author as supporting material and has not been copy-edited or verified by JBJS. Page 1 The following content was supplied by the author as supporting material and has not been copy-edited or verified by JBJS. Appendix TABLE E-1 Care-Module Trigger Events That May Indicate an Adverse

More information

Original Investigation

Original Investigation Research Original Investigation Histamine-2 Receptor Antagonists vs Proton Pump Inhibitors on Gastrointestinal Tract Hemorrhage and Infectious Complications in the Intensive Care Unit Robert MacLaren,

More information

Alginates Extended Abstract

Alginates Extended Abstract Alginates Extended Abstract III) Clinical practice guidelines: DeVault KR, Castell DO; American College of Gastroenterology. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux

More information

COMPUS OPTIMAL THERAPY REPORT. Supporting Informed Decisions. À l appui des décisions éclairées. Proton Pump Inhibitor Project Overview: Summaries

COMPUS OPTIMAL THERAPY REPORT. Supporting Informed Decisions. À l appui des décisions éclairées. Proton Pump Inhibitor Project Overview: Summaries OPTIMAL THERAPY REPORT COMPUS Volume 1, Issue 1 March 2007 Proton Pump Inhibitor Project Overview: Summaries Supporting Informed Decisions À l appui des décisions éclairées This Executive Summary is based

More information

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 Mitchell M. Levy MD, MCCM Professor of Medicine Chief, Division of Pulmonary, Sleep, and Critical Care

More information

Bleeding Prevention in an Era of Expanding Combination Antithrombotic Therapies

Bleeding Prevention in an Era of Expanding Combination Antithrombotic Therapies Bleeding Prevention in an Era of Expanding Combination Antithrombotic Therapies Muthiah Vaduganathan, MD MPH Cardiovascular Medicine Brigham and Women s Hospital December 8 th, 2017 Disclosures None Key

More information

Prospective Assessment of Prescribing Pattern of Intravenous Proton Pump Inhibitors in an Indian Tertiary-Care Teaching Hospital

Prospective Assessment of Prescribing Pattern of Intravenous Proton Pump Inhibitors in an Indian Tertiary-Care Teaching Hospital Research Article Prospective Assessment of Prescribing Pattern of Intravenous Proton Pump Inhibitors in an Indian Tertiary-Care Teaching Hospital Shobha Churi*, Arun Jogani Department of Pharmacy Practice,

More information

Complications of Proton Pump Inhibitor Therapy. Gastroenterology 2017; 153:35-48 발표자 ; F1 김선화

Complications of Proton Pump Inhibitor Therapy. Gastroenterology 2017; 153:35-48 발표자 ; F1 김선화 Complications of Proton Pump Inhibitor Therapy Gastroenterology 2017; 153:35-48 발표자 ; F1 김선화 Background Proton pump inhibitors (PPIs) are among the most commonly prescribed medicines for gastroesophageal

More information

CYP2C19-Proton Pump Inhibitors

CYP2C19-Proton Pump Inhibitors CYP2C19-Proton Pump Inhibitors Cameron Thomas, Pharm.D. PGY2 Clinical Pharmacogenetics Resident St. Jude Children s Research Hospital February 1, 2018 Objectives: CYP2C19-PPI Implementation Review the

More information

Page 1 of 5 Official reprint from UpToDate www.uptodate.com 2017 UpToDate Patient education: Acid reflux (gastroesophageal reflux disease) in adults (The Basics) Written by the doctors and editors at UpToDate

More information

Nutrition and Sepsis

Nutrition and Sepsis Nutrition and Sepsis Todd W. Rice, MD, MSc Associate Professor of Medicine Vanderbilt University 2017 DNS Symposium June 2, 2017 Case 55 y.o. male COPD, DM, HTN, presents with pneumonia and septic shock.

More information

The Potential For Microbiome Modification In Critical Illness. Deborah Cook

The Potential For Microbiome Modification In Critical Illness. Deborah Cook The Potential For Microbiome Modification In Critical Illness Deborah Cook To review Objectives The microbiome & concepts about its modification during critical illness Interventions Predisposition to

More information

American College of Surgeons Critical Care Review Course 2012: Infection Control

American College of Surgeons Critical Care Review Course 2012: Infection Control American College of Surgeons Critical Care Review Course 2012: Infection Control Overview: I. Central line associated blood stream infection (CLABSI) II. Ventilator associated pneumonia (VAP) I. Central

More information

Proton Pump Inhibitors (PPIs) (Sherwood Employer Group)

Proton Pump Inhibitors (PPIs) (Sherwood Employer Group) Proton Pump Inhibitors (PPIs) (Sherwood Employer Group) BCBSKS will review Prior Authorization requests Prior Authorization Form: https://www.bcbsks.com/customerservice/forms/pdf/priorauth-6058ks-st-ippi.pdf

More information

Mechanical ventilation (MV) is a lifesaving therapy

Mechanical ventilation (MV) is a lifesaving therapy critical care review GI Complications in Patients Receiving Mechanical Ventilation* Gökhan M. Mutlu, MD; Ece A. Mutlu, MD; and Phillip Factor, DO, FCCP Mechanical ventilation (MV) can be lifesaving by

More information

Fecal incontinence causes 196 epidemiology 8 treatment 196

Fecal incontinence causes 196 epidemiology 8 treatment 196 Subject Index Achalasia course 93 differential diagnosis 93 esophageal dysphagia 92 95 etiology 92, 93 treatment 93 95 work-up 93 Aminosalicylates, pharmacokinetics and aging effects 36 Antibiotics diarrhea

More information

Prescribe appropriate immunizations for. Prescribe childhood immunization as per. Prescribe influenza vaccinations in high-risk

Prescribe appropriate immunizations for. Prescribe childhood immunization as per. Prescribe influenza vaccinations in high-risk Supplemental Digital Appendix 1 46 Health Care Problems and the Corresponding 59 Practice Indicators Expected of All Physicians Entering or in Practice Infectious and parasitic diseases Avoidable complications/death

More information

5.3 Strategies to Optimize Delivery and Minimize Risks of EN: Small Bowel Feeding vs. Gastric May 2015

5.3 Strategies to Optimize Delivery and Minimize Risks of EN: Small Bowel Feeding vs. Gastric May 2015 5.3 Strategies to Optimize Delivery and Minimize Risks of EN: Small Bowel Feeding vs. Gastric May 2015 2015 Recommendation: Based on 16 level 2 studies, small bowel feeding compared to gastric feeding

More information